Romanian Journal of Oral Rehabilitation

Vol. 14, No. 1, January - March 2022

MAKING SMILES-SAME OR DIFFERENT PERSPECTIVE FOR

PROSTHODONTIST AND ORTHOTONTIST?

Dana Gabriela Budală1, Monica Mihaela Scutariu1*, Zenaida Surlari2*, Corina

Ciupilan3*, Cristian Romanec4*, Dragoș Ioan Virvescu 2

1-“Gr. T. Popa" U.M.Ph. - Iași, Romania, Faculty of Dentistry, Implantology, Removable Dentures,
Dental Technology
2-“Gr.T.Popa"U.M.Ph.-Iași, Romania, Faculty of Dentistry, Department of Odontology-
Periodontology, Fixed Prostheses
3-Grigore T. Popa" U.M.Ph. - Iași, Romania, Faculty of Medicine, Department of Morpho-
Functional Sciences I
4-“Grigore T. Popa" U.M.Ph. - Iași, Romania, Faculty of Dentistry, Department of Orthodontics

Corresponding author; Monica Mihaela Scutariu e-mail: monascutaru@yahoo.com…

*
All authors have the same contribution as the first author

ABSTRACT : Dental professionals are compelled to perform high-quality dental restorations

because of the indisputable benefits of a beautiful smile. The esthetic planning of the smile is
subjective in the sense that the clinician must be aware of the most significant factors in order to
undertake treatments with a predictable outcome

Keywords: smile parameters, orthodonthics, fixed dentures, etc

INTRODUCTION. The hard-tissue component (i.e., the

A significant improvement in the
population's material and spiritual well-
being has resulted in an increase in demand
for beauty. In social interactions, facial
appearance is extremely important [1].
An attractive smile has been shown
to influence personality development, social
relationships, and job success [2].
Dental professionals are compelled
to perform high-quality dental restorations
because of the indisputable benefits of a
beautiful smile. Before beginning treatment,
specialists must examine the demands of the
patients [3]. Previous research has found a
considerable difference in the assessments of
smile attractiveness across laypeople and
specialists, males and females, and people of
various ages [4-7]. This data can assist
dentists in better understanding how various
people rate their smile. Dental therapy can
progress smoothly once the treatment plan
satisfies a subject's desires.
teeth), the amount of gingival show, and the
framing of the lips displayed in a smile all
contribute to an appealing smile[8,9].
Several definitions and concepts for
smile aesthetics have been proposed by
researchers, including anterior smile line,
smile arc, upper lip curvature, most posterior
visible teeth in a grin, smile index, and
dynamic smile symmetrization [10,11].
These smile beauty qualities were
used as the major criterion for professionals
to use when developing a treatment plan.
The importance of gingival presentation in
developing an aesthetically pleasing smile is
often overlooked by specialists who focus on
hard-tissue aesthetics such as tooth location,
size, shape, and color [12,13].
Clinical criteria such as interdental
gingiva height, gingival zenith (GZ) point
position, gingival line direction, and gingival
symmetry are crucial in addition to healthy
gingiva characteristics [14].

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 Romanian Journal of Oral Rehabilitation
Vol. 14, No. 1, January - March 2022
Surprisingly, the definition of beauty
varies by country and ethnicity. Several
research on Caucasian people have been
undertaken to analyze smile traits and
related factors, but no equivalent data exists
for Asian populations [15].
CLINICAL IMPLICATIONS
The esthetic planning of the smile is
subjective in the sense that the clinician
must be aware of the most significant factors
in order to undertake treatments with a
predictable outcome.
In a patient's smile, the smile line is
quite crucial. The amount of dental and
gingival tissue revealed during movements
should be examined as well as the size and
contour of the lips (static analysis) (dynamic
analysis).
The length of the maxillary lip and
its range of movement govern the degree of
tooth display in a smile, resulting in a
variety of smiles, with excessive gingival
display deemed unattractive. The amount of
tooth displayed in a smile is valued
differently depending on the observer [16-
18].
Clinical dentistry faces the difficulty
of achieving function, health, and aesthetics
all at the same time. Because of its
subjective nature, the esthetic result is the
most difficult to quantify. To achieve
symmetry, harmony, balance, and proportion
in their treatments, dentists must supplement
their technical skills and scientific
understanding with a knowledge of the arts.
The impression of attractiveness in a
smile is influenced by its composition, and
in the natural dentition, principles have been
presented. When repairing esthetically
problematic situations, these guidelines have
been generalized [19].
Different metrics, such as midline
coincidence and symmetry on each side of
the midline, have been employed to provide
an objective esthetic analysis in a systematic
and dynamic manner.
There is a loss of alignment between
the facial and dental midlines in 14.3% to
31.6 percent of patients, according to studies
[20]. Lack of midline alignment has been
66
investigated with the goal of determining the
point at which deviation becomes
unattractive to the general public.
The beginning point for an esthetic
and functional treatment plan is the position
of the maxillary central incisors. Because the
lateral incisors are smaller, the maxillary
anterior incisal margins and lower lip appear
as "gull wings." [21].
The buccal corridors are formed as
the mouth expands to make a grin and dark
regions appear between the exterior of the
maxillary teeth and the labial commissure.
These buccal corridors are negative
areas that come from the gap between the
breadth of the maxillary arch and the width
of the grin. They have an aesthetic effect and
are dependent on the number of maxillary
teeth visible [22-25].
Diastemas have been reported to
adversely affect a smile. Some grin
characteristics alter with age, particularly the
amount of maxillary and mandibular teeth
exposed during a smile. Many of the other
variables are fixed [26].
THE ORAL REGION AND ESTHETICS
The smile is mostly expressed
through the mouth and eyes. The top and
lower lips, the corners of the mouth, and the
anterior section of the cheeks are all part of
the oral region.
The nasolabial grooves, if present,
go from the nose to the angles of the mouth
and may extend inferiorly through the oral
region. The philtrum is a vertical dip of the
upper lip that extends from the nose septum
to the red zone and is usually present.
The lips are two highly movable
fleshy folds that surround the mouth's
opening. Their anatomy changes when they
are resting. They might be thick or thin,
wide or narrow, short or long, all depending
on genetics and the shape of the teeth.
Lips that are too thin are usually
stretched; this is due to a lack of muscle
mass. Externally, the lips extend from the
base of the nose to the contact line,
including the exposed red zone? The red
zone of the lips forms a curving elevation
and meets the skin at an oblique angle in
 Romanian Journal of Oral Rehabilitation
Vol. 14, No. 1, January - March 2022
most cases [27].
Between the red zone of the lip and
the base of the nose, there is a depression;
between the lower lip and the chin, there is a
similar but larger depression. In a profile
view, the curve of the lips and the
person, the lips recede, enhancing the
prominence of the nose and chin.
At rest, the lips may meet in a
straight line or slope upward or downward
toward the corners in a facial view. The
small top lip frequently curls upward, stays
open, and creates an acute angle at the
corners. Dentists can change the position of
.
SIMLE ANATOMY
A true smile is a complex gesture.
Viewed from the facial aspect the smile
begins as the corners of the mouth extend
laterally. Except for persons with a small
upper lip, the lips may remain in contact.
The lips part, the corners of the mouth
curve upward, and the teeth are exposed to
view as the smile expands and approaches
laughter. Some people only exhibit their
maxillary teeth, while others only show their
mandibular teeth. Some people display both.
The mesial half of the maxillary first molars
and the mandibular second premolars may
be revealed as the angles of the mouth widen
and the lips separate. While most people do
not expose their gingival tissues when
smiling, those with a small upper lip
invariably do [30].
While most people do not expose
their gingival tissues when smiling, those
with a small upper lip invariably do. In a
broad smile, those with hypermobile lips or
huge alveolar processes may do the same.
The jaws separate as the smile
progresses to a laugh, and a dark area forms
between the maxillary and mandibular teeth.
Isn't this space sometimes referred to as
negative space? After that, the teeth are
silhouetted against the black background.
While individual teeth in a complete
dentition are undetectable, missing teeth and
diastemas stand out because they interrupt
the normally peaceful black space. A visual
67
concavities in the skin are more visible [28].
The lips may be abnormally
prominent or recessive due to the inclination
of the teeth. Because the interarch distance
may be reduced and the nose and chin tend
to resemble each other in the edentulous
natural or artificial teeth to preserve or alter
the relationships between the visible
components of the oral region and the oral
cavity [29].
The most difficult aspect of
achieving esthetic excellence is achieving
harmony between the components of the oral
region and oral cavity.
impact of surprise is created by anomalies in
the dark space's configuration[31].
The earliest sign of a smile is a
thinning of the lips and a distal extension of
the corners of the mouth when viewed from
the side. This continues until the lips expand
wide enough to reveal teeth. The dark area
remains, and the tongue may or may not be
seen, as in the facial view.
The dentist is concerned with the
aesthetics of the oral region of the face.
Although a component may be unpleasant in
and of itself, the way lips, teeth, and dark
space mix creates the balance that makes the
mouth region appealing. An individual tooth
may be rotated, shorter, or somewhat
overlapped than one on the opposite side.
These little flaws give the grin personality,
breaking up the artificiality and monotony of
near-perfection.
Major interruptions of the black
region, on the other hand, detract from the
overall impression of the smile in adults. For
the majority of patients, their natural smile is
becoming increasingly important and should
be kept. A dentist may usually repair a
bothersome aspect, but both the patient and
the dentist must agree on what constitutes
improvement [32-24].
Because the dentist has a
responsibility to preserve or improve the
look of the oral region, an accurate record of
what exists and what should be modified is
required prior to treatment. In both resting
and smiling positions, all characteristics of
 Romanian Journal of Oral Rehabilitation
Vol. 14, No. 1, January - March 2022
the oral region should be noted. The dentist
can use a smile anatomy chart to note the
teeth that are visible, the extent to which
they are visible, the curve of the lips, the
length of the lips, and the all-important black
area [35].
Attractiveness, IQ, personality, and
actions are all influenced by malocclusions.
People with a normal occlusion are thought
to be more attractive, clever, pleasant, and
outgoing; anterior crossbites are thought to
be unattractive, while people with many
diastemas are thought to be the least
conscientious and agreeable [36]. People
with perfect smile were judged smarter and
more fit for the job, according to a recent
study of the effect of tooth arrangement on
human resources staff [37]. Discrimination
against people with facial peculiarities is
very common, and the quest for solutions to
improve face esthetics, such as orthodontic
treatment, orthognathic surgery, or cosmetic
treatments, has grown in popularity over
time. The goal of facial attractiveness
research is to figure out which face
characteristics are linked to attractiveness.
Some studies have demonstrated a
preference for symmetrical and average
faces, yet beautiful faces have unique traits
that go beyond the ordinary.
Clinically, the closer the central
incisors are to the dental midline, the more
noticeable any changes in smiles are; this
justifies the numerous research studying the
association between vertical location of the
central incisors and a pleasant smile.
Nonetheless, the literature on these
alterations in canines is still largely
unexplored. There are no studies that
compare the variables of incisal edges and
gingival margins when the canines' vertical
position is changed without changing the
dental crown size.
Because well-established canine
guides are necessary for a healthy
masticatory system, the canine vertical
position is an important aspect in smile
SMILE PREFERENCES
68
esthetics and occlusion functionality. Other
factors such as the eyes, nose, and face
shape, according to some experts, have little
bearing on the perception of a smile.
Other studies have revealed that
when close-up photographs are used instead
of full-face images, the perception of smile
details is more relevant, and that this
strategy may reduce the distractions of facial
traits and lead to a greater focus on dental
modifications [38,39]. According to
research, a small gingival show enhances the
attractiveness of a smile.
According to the literature,
asymmetries higher than 0.5 mm at the
gingival margin of the maxillary canines are
regarded unsightly, and symmetric changes
are preferable to asymmetric changes [40].
Gingival hyperplasia, gingival
recession, overeruption, changes in form and
tooth size, and traction of an included canine
can all cause alterations in the canine
gingival margins in clinical practice. If the
maxillary lateral incisors are missing, which
is more prevalent unilaterally, a viable
approach is to replace the missing incisor
with the canine, which has the premolar's
space. The gingival contour of the premolar,
which becomes more evident after the
altered dental location, is often below the
gingival edge of the contralateral canine,
causing esthetic pain. Patients with such
modifications may benefit from periodontal
plastic surgery, intrusion and restoration of
premolar incisal margins, or extrusion of the
contralateral canine and incisal wear,
according to the literature [41-43]
Canine extrusion during appliance
bonding or wire bending during finishing to
provide lateral functional guidance may
have a negative impact on smile aesthetics,
which orthodontists should be aware of.
Grinding the cusps, depending on the
structure of the maxillary canines, may
readily create favorable esthetic effects in
some patients.
One of the most common reasons
people seek dental treatment is to improve
their facial and dental attractiveness, as a
 Romanian Journal of Oral Rehabilitation
Vol. 14, No. 1, January - March 2022
smile has a significant impact on facial
Ackerman et al noted that a posed
frontal smile, which is voluntary and
reproducible over time, is beneficial to
orthodontic therapy. During routine data
collection, this should be noted. In real life,
however, the attractiveness of a smile is not
assessed based solely on a frontal
perspective [44].
According to Dierkes, a beautiful
smile is achieved by balancing the
horizontal, vertical, and transverse
components of the face features.
Furthermore, Hulsey stressed the importance
of the anteroposterior dimension in
malocclusions, stating that information
about the connection between teeth and
surrounding soft tissue in the frontal view is
required for a basic assessment of facial
Patients' and dentists' views of
variance in the appearance of the anterior
teeth and their relationship to the
surrounding soft tissue were investigated by
Kokich et al [48]. Their findings revealed
that orthodontists, general dentists, and
individuals have diverse perceptions of
maxillary midline deviation and incisal
plane cant discrepancies.
According to Janson et al, a little
dental midline deviation of 2.2 mm is
acceptable to both orthodontists and people,
but buccal corridor diameters and smile arc
have no effect on smile beauty [49].
Both people and orthodontists prefer
a smile arc parallel to the lower lip and
minimal buccal corridors, according to
Parekh et al, whereas smile arc flattening
and excessive buccal corridors are
considered unattractive traits [50].
According to An et al, dentists are
better at identifying changes in dental
midline shifts and incisal plane canting than
patients; also, orthodontically treated people
are more critical of incisal plane canting and
dental midline shifts than nontreated patients
[51].
Several studies have been
undertaken to evaluate whether dental
professionals and people have different
preferences for smile esthetics. Individual
patients and dentists may have various
69
esthetics in everyday social interactions.
esthetic. To determine smile improvement
following treatment, dentists should evaluate
smile composition in the frontal, three-
quarter, and lateral views [45-47].
Smile esthetic is a subjective concept
that is influenced by a person's past
experiences and social surroundings.
Furthermore, due to varying dental
experiences, dental experts and the general
public have different preferences for an
esthetic smile.
As a result, during orthodontic
treatment planning, patients' opinions and
preferences toward smile esthetics must be
taken into account. Orthodontists should also
evaluate the various aspects of a beautiful
smile, which varies from one patient to the
next.
aesthetic smile preferences, which
necessitates an examination of esthetic smile
preferences. The outcomes of such
evaluations give dentists pointers on how to
communicate with orthodontic patients.
Several studies have analyzed the effect of
buccal corridors on smile attractiveness and
concluded that large buccal corridors are
considered less attractive.
These findings should be considered
in orthodontic treatment planning because
orthodontic treatment can broaden the smile
by expanding the narrow dental arch and
reducing the buccal corridor space to
improve esthetics. Machado stated that
buccal corridors should ideally be average,
followed by narrow or nonexistent ones, and
Sharma et al reported that the existence or
not of buccal corridors and their esthetic
evaluation depended greatly on the ethnic
origins of both participants and observers
[52,53].
Regarding the upper lip thickness,
the general dentists, orthodontic patients,
and patients selected 5-mm upper lip
thickness as the most attractive in the lateral
view. However, orthodontists selected a
thickness of 7 mm, similar to that reported
by McNamara et al [54].
CONCLUSIONS
 Romanian Journal of Oral Rehabilitation
Vol. 14, No. 1, January - March 2022

Many factors can affect the
establishment of esthetic beauty standards,
such as income, age, and culture, and this
implies that the ideals of beauty are
constantly changing
Patients' expectations for dental
treatment have risen in response to the
growing need for facial esthetics, resulting
in the creation of increasingly effective
therapeutic procedures. Few studies have
been conducted to date to determine the
impact of these beauty standards and their
variations on the attractiveness of a smile.

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